The need for new and better antidepressants: reboxetine a new option.

The selective serotonin reuptake inhibitors (SSRIs) have obtained global attention but have not demonstrated superior efficacy in major depression compared with older tricyclic antidepressants. From a pharmacological viewpoint the noradrenergic system in the brain appears to have a central role in neurotransmitter organization. The importance of noradrenaline in depression is supported by its association with clinical parameters such as vigilance and drive. Reboxetine is a selective noradrenaline reuptake inhibitor--the first in its class to be marketed. In both preclinical and clinical studies reboxetine has been found to be an effective and safe antidepressant. Furthermore, reboxetine restores a patients' social functioning, producing a better quality of remission than fluoxetine.

Social activities in elderly patients with severe mental illness. Lessons from a mental hospital in Sweden.

Mental hospitals offer their patients many different kinds of social activities/facilities. One-hundred-and-twenty-seven patients in the long-term care unit at a mental hospital were included in the study. They were divided into three subgroups on the basis of diagnosis: dementia disorder (n = 65), chronic psychotic disorder (n = 38), and chronic non-psychotic disorder (n = 24). An inventory was made of all possible activities/facilities offered to the patients by the mental hospital, with the objective of ascertaining whether participation in social activities/facilities discriminated between the three diagnostic groups. Sixteen activities/facilities were obtained from an inventory by nurses. Stepwise discriminant analysis identified length of stay in hospital, age and the social activities/facilities that separated the three diagnostic groups. The discriminant function analysis showed that participation in social activities, together with length of stay and age, discriminated very well between the demented and the chronic psychotic groups. The discriminant analysis also indicated that patients with chronic psychotic. disorder were distinguishable by their frequent participation in social activities, long stay in hospital, and low age. The results obtained can be used when the social activities/facilities in a community care setting are being planned for the various diagnostic groups.

The need for quality assurance for a better compliance and increased quality of life in chronic schizophrenic patients.

In many places in the world community care facilities for chronic schizophrenic patients are insufficient, leading to a series of complications which can even be fatal. The lack of facilities contributes to a decrease in patients' compliance. The establishing of a good community care programme for the whole disease period will also considerably increase the efficacy of relapse prevention and give the patient an acceptable quality of life, and hopefully increase the patient's compliance. There is urgent need for therapy standards to be assured and monitored according to strict evaluation criteria to produce a better interplay between the schizophrenic patient and psychiatric staff.

A long-term cross-over pharmacokinetic study comparing perphenazine decanoate and haloperidol decanoate in schizophrenic patients.

The purpose of the study was to investigate clinical and pharmacokinetic parameters concerning perphenazine decanoate (PD) and haloperidol decanoate (HD) with an interval of 3 weeks during a study period of 51 weeks. This was done by using the available drug preparations in chronic schizophrenic patients in a randomised, double-blind, cross-over, multicentre study. In addition, an elimination phase of 6 weeks was added, when no IM injections of the depot drugs were given. Twenty-nine patients in a stable neuroleptic maintenance phase entered the study. The patients were rated during the trial according to the CPRS-SCHZ and CGI scales, the UKU side effect scale and serum concentrations of the drugs and prolactin were monitored. There was no significant difference between the drugs in antipsychotic efficacy or side effects. Thus, the doses were equipotent with regard to the CPRS-SCHZ scores. However, the patients' global improvement rating was higher for PD (52%) than for HD (39%) (P > 0.05). The elimination of both drugs was very slow. No interaction effects between PD and HD were observed. The serum levels of HD were in most patients lower than those recommended for acute-subacute treatment. The mean doses were 117 mg (0.29 mmol), range 20-313 mg PD and 120 mg (0.32 mmol), range 20-350 mg HD. The serum concentrations in nmol/L of perphenazine and haloperidol (week 24) were 0.8-15.9 and 2.3-46.7, respectively.

Does community care reduce the need for psychiatric beds for schizophrenic patients?

For schizophrenics, the closing down of the old traditional hospital has in many places ended up in a scenario characterized by homelessness, relapse, patients overcrowding acute psychiatric but also somatic hospital wards, increased suicide figures, low living standards--and an increased burden on the family. The beds for schizophrenics have been considerably reduced in many countries. For schizophrenia the critical low number of institution beds--hospital as well as nursing home--seems to be 0.07% of the general population. Schizophrenia in all phases must be treated as the disease it is, not as a social problem.

A controlled Nordic multicentre study of zuclopenthixol acetate in oil solution, haloperidol and zuclopenthixol in the treatment of acute psychosis.

Zuclopenthixol acetate--a new injectable formulation with a duration of action of 2-3 days--was compared with conventional intramuscular and oral formulations of haloperidol and zuclopenthixol in the initial treatment of acutely disturbed, psychotic patients. The patients were stratified into 3 diagnostic categories: acute psychoses (48 patients), mania (22 patients), and exacerbation of chronic psychoses (73 patients). The patients were rated on the Brief Psychiatric Rating Scale (BPRS), the Bech-Rafaelsen Mania Rating Scale (BRMAS) (only manic patients) and globally on the Clinical Global Impression (CGI). The study was an open, randomized multicentre trial with a 6-day treatment period. The zuclopenthixol acetate patients received 1-4 doses, the haloperidol patients 1-26 and the zuclopenthixol patients 1-22 doses. The assessments on the CGI showed that all 3 treatments caused a clear reduction of the severity of illness scores in all 3 diagnostic categories, with no differences between treatments. The ratings of the acute and chronic psychotic patients on the BPRS also showed significant reductions in scores with no differences between treatments. All 3 treatments caused a rapid remission of symptoms on the BRMAS. Haloperidol induced hypokinesia in significantly more patients than zuclopenthixol acetate after 24 h. Later there were no significant differences between treatments. Zuclopenthixol acetate fulfils many desires for an amended neuroleptic formulation for the initial treatment of acutely disturbed psychotic patients.

Comparison of quality of life with standard of living in schizophrenic out-patients.

Standard of living reflects the objective dimension of how well the basic needs of life are met, while quality of life is the patient's own subjective view of well-being and satisfaction with her/his life. Sixty-one schizophrenic out-patients completed self-report inventories and participated in interviews about quality of life and standard of living. When living standards were met by a well functioning social service system, patients' perceptions of their quality of life and their standard of living appeared to be independent. Subsequent analyses revealed that 'inner experiences' was one quality-of-life domain frequently reported as unsatisfactory. Moreover, differences in quality of life were found across patients' age, education, and work status.

Quantification of naturally occurring benzodiazepine-like substances in human breast milk.

The possible occurrence of benzodiazepine-like substances in human breast milk was investigated in 35 healthy, newly delivered women who were known not to be taking benzodiazepines. Maternal blood samples and a sample of breast milk were obtained on the fifth post partum day. A radioreceptor technique (lower limit of detection 1.5 ng/ml; difference between duplicates at various concentrations less than 7%) was used for measuring benzodiazepine-like substances in blood and breast milk (with and without prior extraction). No benzodiazepine-like substances could be demonstrated in any of the blood samples taken from the 35 women. Measurable concentrations of benzodiazepine-like substances were demonstrated in all but 1 of the 35 breast milk samples. The mean concentration of benzodiazepine-like substances for all 35 women was 4.3 +/- 2.3 ng/ml (range 0-9.3 ng/ml) expressed as lorazepam. The corresponding value for extracted breast milk was 2.6 +/- 1.5 ng/ml (range 0-7.0 ng/ml). There was no association between concentrations of benzodiazepine-like substances in breast milk and maternal age, weight, height and body mass or parity, or the sex of the infant and infant birth weight. We suggest that non-detectable amounts of benzodiazepine-like substances in serum are concentrated in the mammillary glands and excreted in a higher concentration in breast milk. It is less likely that the relevant benzodiazepines are produced in the mammillary glands.

Electromechanical characteristics of tardive dyskinesia.

Fifty patients with mild-to-moderate tardive dyskinesia (TD), who were devoid of other clinically apparent movement abnormalities, and 70 neurologically normal controls were assessed with a battery of instruments developed to measure and analyze the hyperkinetic movements of TD directly, objectively, and noninvasively. The electro-mechanical features that most consistently characterized and differentiated the TD group were a greater variability of all movements, increased energy in the 1-2 Hz frequency band in hand and foot movements, and a marked increase in movements during distracting tasks. This instrumentation promises to be useful in quantitating abnormal involuntary movements, in prospectively following individual patients to scan for small deviations from an instrument-established baseline, and in examining patients with combined movement abnormalities.

Defining treatment refractoriness in schizophrenia.

Addressing the need for research on the nature of refractoriness to antipsychotic drug therapy exhibited by a substantial minority of schizophrenic patients, Philip R.A. May and Sven Jonas Dencker instigated an international study group to discuss this problem, beginning with the International Congress of Neuropsychopharmacology in Göteborg, Sweden, in 1980. The study group subsequently met in Haar, Federal Republic of Germany, in 1985; in Banff, Canada, in 1986; and again in Telfs, Austria, in 1988. The study group set three objectives: (1) to clarify the concept of treatment resistance or refractoriness; (2) to suggest criteria for defining or rating the degree of treatment refractoriness; and (3) to explore the role of psychosocial and drug therapies in increasing the responsiveness of the treatment refractory patient. This position article represents a distillation of the study group's efforts to define treatment refractoriness in schizophrenia.